have you got the full set of gases?
Simon Carley
SpR in Emergency Medicine
Manchester Royal Infirmary
Manchester
England
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-----Original Message-----
From: Meek, Steve <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Date: 16 February 2000 12:22
Subject: VT and acidosis
>Thoughts from the lists' collective brains welcome for a situation I have
>not previously come across
>
>73 year old man, under treatment for panic attacks arrives in sinusoidal
VT,
>clammy, central pulses, no BP, talking. On amytriptiline. Rapidly given
>midazolam and DC shock x 1 200J - into SR. Immediate 12 lead is completely
>normal, no iscahemia, and we were interested to note he had not a single
>ectopic on the monitor. BP then recorded as 140/80. Unconscious from the
>midazolam but things seemed to be going OK.
>Gases taken immediately post shock show gross metabolic acidosis, pH 7.0.
>Receiving IV saline though lungs wet and JVP in his exernal auditory
meatus.
>
>His myocardium then became increasingly irritable 15 minutes or so post
>shock - increasing VE's and n/s bursts of VT. I had just put up a nitrate
>infusion and stopped it as his BP progressively fell to 90 systolic. Given
>lignocaine bolus and infusion and magnesium 2g, to no effect. Remained
>hypotensive, flumazenil given to reverse his sedation. Over the next 30
>minutes he remained hypotensive, systolics around 90-100 but increasingly
>well perfused peripherally. Central access obtained and amiodarone given,
>lignocaine tailed off.
>
>My questions
>why the delayed myocardial irritability? Is it related to peripheral
>reperfusion?
>why didn't it respond to lignocaine?
>Would anyone have done an RSI rather than just midazolam? My reason was
time
>- he looked close to losing output but obviously I left his airway at risk.
>
>Steve Meek
>RUH Bath
>
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